IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


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Photographic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


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CIHM/ICMH 

Microfiche 

Series. 


CIHIVI/ICIV/IH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microroproductions  historiques 


CV 


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Technical  and  Bibliographic  Notes/Notes  tachniquas  at  bibliographiquas 


The  Institute  has  attempted  to  obtain  the  best 
original  copy  available  for  filming.  Features  of  this 
copy  which  may  be  bibliographically  unique, 
which  may  alter  any  of  the  images  in  the 
reproduction,  or  which  may  significantly  change 
the  usual  method  of  filming,  are  checked  below. 


0 


D 


D 

D 


D 


D 


Coloured  covers/ 
Couverture  de  couleur 


I      I    Covers  damaged/ 


Couverture  endommagie 


Covers  restored  and/or  laminated/ 
Couverture  restaur^e  et/ou  pelliculie 


I      I    Cover  title  missing/ 


Le  titre  de  couverture  manque 


□    Coloured  maps/ 
Cartes  giographiques  en  couleur 


D 


Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  couleur  (i.e.  autre  que  blaua  ou  noire) 


Coloured  plates  and/or  illustrations/ 
Planches  et/ou  illustrations  en  couleur 


Bound  with  other  material/ 
Relid  avec  d'autres  documents 

Tight  binding  may  cause  shadows  or  distortion 
along  interior  margin/ 

La  re  liure  serr^e  peut  causer  de  I'ombre  ou  de  la 
distorsion  le  long  de  ia  marge  intdrieura 

Blank  leaves  added  during  restoration  may 
appear  within  the  text.  Whenever  possible,  these 
have  been  omitted  from  filming/ 
II  se  peut  que  certaines  pages  blanches  ajouties 
lors  d'une  restauration  apparaissent  dans  le  texte, 
mais,  lorsque  cela  dtait  possible,  ces  pages  n'ont 
pas  6t6  film^es. 

Additional  comments:/ 
Commentaires  suppldmentaires; 


L'Institut  a  microfilme  le  meilleur  exemplaire 
qu'il  lui  a  iti  possible  de  se  procurer.  Les  details 
de  cet  exemplaire  qui  sont  peut-dtre  uniques  du 
point  de  vue  bibliographique,  qui  peuvent  modifier 
une  image  reproduite,  ou  qui  peuvent  exiger  une 
modification  dans  la  mithode  normale  de  filmage 
sont  indiquis  ci-dessous. 


r~|    Coloured  pages/ 


D 


Pages  de  couleur 

Pages  damaged/ 
Pages  endommagdes 

Pages  restored  and/oi 

Pages  restaur^es  et/ou  pelliculies 

Pages  discoloured,  stained  or  foxei 
Pages  ddcolories,  tachatdes  ou  piqudes 

Pages  detached/ 
Pages  d^tach^es 

Showthrough/ 
Transparence 

Quality  of  prir 

Quality  indgale  da  I'impression 

Includes  supplementary  materii 
Comprend  du  materiel  suppldmentaire 

Only  edition  available/ 
Seule  Edition  disponible 


|~~|  Pages  damaged/ 

I      I  Pages  restored  and/or  laminated/ 

r~^  Pages  discoloured,  stained  or  foxed/ 

I      I  Pages  detached/ 

r~r|  Showthrough/ 

I      I  Quality  of  print  varies/ 

I      I  Includes  supplementary  material/ 

r~~\  Only  edition  available/ 


Pages  wholly  or  partially  obscured  by  errata 
slips,  tissues,  etc.,  have  been  refilmed  to 
ensure  the  best  possible  image/ 
Les  pages  totalement  ou  partiellement 
obscurcies  par  un  feuillet  d'errata,  une  pelure, 
etc.,  ont  6t6  filmdes  d  nouveau  de  fapon  d 
obtenir  la  meilleure  image  possible. 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  film^  au  taux  de  reduction  indiqud  ci-dessous. 


10X 

14X 

18X 

22X 

26X 

30X 

y 

12X 


16X 


20X 


24X 


28X 


32X 


Th«  copy  filmed  hare  has  been  reproduced  thank* 
to  the  generosity  of: 

(Medical  Library 
McGill  Univeriity 
IVIontreal 

The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  iceeping  with  the 
filming  contract  specifications. 


Original  copies  In  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  iliustrated  impression. 


L'exemplaire  fllmA  fut  reproduit  grAce  k  la 
ginirosit^  da: 

IVIedical  Library 
McGill  Univeriity 
IVIontreal 

Lee  images  suivantes  ont  AtA  raproduites  avec  ie 
plus  grand  soin,  compte  tenu  de  la  condition  at 
de  la  nettetA  de  l'exemplaire  filmA,  at  en 
conformiti  avec  las  conditions  du  contrat  de 
filmage. 

Lea  exemplaires  originaux  dont  la  couverture  en 
papier  est  ImprimAe  sont  fllmAs  en  commenpant 
par  Ie  premier  plat  at  en  terminant  soit  par  la 
dernlAre  page  qui  comporte  une  empreinte 
d'Impresslon  ou  d'lllustration.  soit  par  ie  second 
plat,  salon  Ie  cas.  Tous  las  autres  exemplaires 
originaux  sont  filmte  an  commandant  par  la 
premiere  page  qui  comporte  une  empreinte 
d'impression  ou  d'lllustration  at  en  terminant  par 
la  deinlAre  page  qui  comporte  une  telle 
empreinte. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  — ^  (meaning  "CON- 
TINUED"), or  the  symbol  y  (meaning  "END"), 
whichever  applies. 


Un  dee  symboles  suivants  apparaftra  sur  la 
dernlAre  imege  de  cheque  microfiche,  selon  Ie 
cas:  Ie  symboie  «*>  signifle  "A  SUIVRE",  Ie 
symbols  Y  signifle  "FIN". 


l\/laps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


Lea  cartes,  planches,  tableaux,  etc.,  peuvent  Atre 
filmAs  A  dee  taux  de  reduction  diffdrents. 
Lorsquc  Ie  document  est  trop  grand  pour  Atre 
reproduit  en  un  seul  clichA,  11  est  filmA  A  partir 
de  I'angle  supArieur  gauche,  de  gauche  A  droite, 
et  de  haut  en  bas,  en  prenant  Ie  nombre 
d'images  nAcessaire.  Lee  diagrammes  suivants 
illustrent  la  mAthode. 


1 

2 

3 

1 

2 

3 

4 

5 

3 

I 


IjJ  0-"  '^  »  ,^.0^' 


M 


Letters  to  my  Hospital  Internes, 
Past  and  Present. 


BY  CASEY  A.  WOOD,  M.D. 


CHICAGO. 


REPRINTED  FROM 
THE  JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOOiATION. 

AUGUST  10,  17  and  U,  1896. 


CHICAGO: 

Ahkrican  Medical  Associatiom  Prsss. 

1885. 


mma 


Lottei*s   to  my  IIo8i>ltal  Internes,  Past  and 

Present. 


By  Casey  A.  Wood,  M.D.,  op  Chicago. 


London,  July  1, 1895. 

(Ifuth'iiicn: — Undoubtedly  there  are  some  forms  of  service 
which  must  ever  leave  the  recipient  in  the  debt  of  the  donor. 
In  looking  back  at  the  work  done  for  me  by  you,  during  my 
attendance  at  Cook  County  Hospital,  the  Alexian  Bros.,  the 
Emergency  Hospital  and  the  Hospital  of  the  Post  Graduate 
Medical  School  it  occurred  to  me  that  I  might  at  least 
acknowledge  certain  obligations  of  this  kind  by  recounting 
some  of  my  experiences  during  a  short  trip  abroad.  I  shall 
endeavor  to  avoid  the  style  of  the  medical  guide  book  and 
beg  to  assure  you  that  I  will  speak  only  of  those  men  and 
those  things  that  came  under  my  own  personal  observation. 
I  might  also  explain  that,  although  this  visit  to  the  English 
and  continental  clinics  has  been  a  hurried  one,  its  value  to 
you  is  possibly  somewhat  enhanced  by  the  fact  that  I  had 
gone  over  more  leisurely  on  two  previous  occasions,  and  at 
an  interval  of  several  years,  practically  the  same  ground. 

The  London  hospitals  have  not  altered  much  since  my 
last  experience  of  them.  The  student  has  not  much  to  gain 
from  a  short  stay  in  the  British  capital,  partly  on  account 
of  the  great  distances  that  must  be  covered  in  going  from 
hospital  to  hospital,  and  partly  because  the  average  English- 
man does  not  take  kindly  to  the  stranger  until  he  has 
become  acquainted  with  him  after  a  proper  introduction. 
But  for  the  man  who  will  settle  down  for  six  months  or  a 
year  and  work  hard,  excellent  teaching  and  numerous 
opportunities  are  at  the  disposal  of  the  visitor.  There  are 
admirable  post  graduate  courses,  conducted  by  the  best 
men  in  London,  on  all  medical  and  surgical  subjects,  but  it 
is  rather  fatiguing   to   hurry  about  from  one  hospital  to 


another,  miles  apart.  Some  day  these  isolated  teachers  may 
come  together,  as  with  us  or  as  in  Vienna,  at  a  common  cen- 
ter, and  then  London  will  compete  on  more  than  even  terms 
with  her  continental  rivals. 

These  objections  do  not  apply  with  the  same  force  to 
ophthalmology  or  otology.  The  student,  advanced  or  other- 
wise, can  hardly  wish  for  more  or  better  opportunities  than 
are  to  be  had  at  the  Royal  London  Ophthalmic  Hospital 
(Moorflelds,  E.  C,  three  daily  clinics,  9  a.m.  to  3  p.m.,  opera- 
tions eleven  to  seventeen  and  Westminster  Ophthalmic, 
Charing  Cross,  3  daily  clinics,  1:30  to  4,  operations  two  to 
three).  I  do  not  say  that  other  excellent  institutions  do  not 
also  furnish  numerous  opportunities  for  work,  because 
large  daily  clinics  are  held  at  the  Central  London  Ophthal- 
mic Hospital  (Gray's  Inn  Road,  W.  C.)  South  London  Oph- 
thalmic Hospital  (near  the  Elephant  and  Castle)  and  in  con 
nection  with  many  of  the  general  hospitals,  but  at  the  two 
special  institutions  first  mentioned  from  forty  thousand  to 
fifty  thousand  new  patients  are  yearly  admitted.  In  that 
overwhelming  tide  of  ophthalmic  disease,  fed  by  the  whole 
country  round  about,  every  possible  type  and  variation  of 
ocular  trouble  can  be  studied.  It  is  a  comparatively  easy 
matter  to  attach  one's  self  at  Moorfields  to  the  service  of 
Nettleship,  Lang,  Silcock,Morton,Gunn,Lawfordor  Couper, 
or  at  the  Westminster  Hospital  to  the  clinics  of  Jaler,  Hart 
ridge,  Cowell,  Dodd,  Donald,  Gunn,  Griffith  and  several 
others.  After  a  month  or  two  of  probation  it  is  possible  to 
obtain  almost  complete  charge  of  patients,  to  do  minor  oper- 
ations and  to  discuss  with  the  chief  of  the  clinic,  matters 
that  arise  in  connection  with  the  conduct  of  their  cases.  Al 
Moorfields,  instruction  on  the  use  of  the  ophthalmoscope 
(unusually  good,  each  course  six  weeks,  plenty  of  cases,  fee 
2  guineas)  is  given  three  times  weekly  by  Gunn,Sncock  and 
Lawford.  Classes  in  refraction  are  conducted  by  Mr.  Lan^ 
(excellent,  one  month  each,  2  guineas)  while  Mr.  Morton 
gives  an  instructive  course  (six  weeks,  1  guinea,  material 
from  all  the  clinics)  on  external  diseases  of  the  eye  every 
Friday  at  1  p.m.  These  courses  are  held  during  the  wintec 
season  and  tickets  are  to  be  had  from  the  secretary  at  thi- 
hospital. 


For  beginners,  ]Mr.  Phillips,  the  refraction  assistant,  con- 
ducts, when  requested,  private  classes  which  are,  in  my  opin- 
ion, superior  to  anything  to  be  had  on  the  continent. 
Indeed,  all  the  continental  clinics  —  especially  those  in 
N'ienna  —  are  conspicuously  weak  in  courses  devoted  to 
the  study  of  refractive  errors  and  muscular  anomalies. 
Mr.  Morton  also  gives  an  excellent  operative  course  (pri- 
vate, six  lessons,  2'.j  guineas)  wiiich  is  very  popular  with 
students.  Pigs'  eyes  and  the  mask  are  employed  for  opera- 
tiiins  on  the  globe  ;  pigs'  heads  for  operating  on  the  extrin- 
sic ocular  muscles  and  the  lids. 

These  excellencies  in  the  way  of  instruction  are  com- 
l)leted  by  work  in  the  laboratory  under  the  supervision  and 
tielp  of  a  very  genial  man,  Mr.  Marshall.  His  predecessor, 
Treacher  Collins,  has  done  and  is  still  doing  a  great  deal  of 
valuable  original  work  and,  mainly  in  consequence  of  his 
ffforts,  the  museum  possesses  by  far  the  best  anatomic  col- 
lection in  the  country. 

I  was  interested  in  a  plan  for  using  the  electric  light  in 
the  examination  of  eye  patients.  As  you  are  aware,  my 
objection  (which  I  had  vainly  endeavored  to  remove  by 
various  devices)  to  this  light  was  the  ditliculty  of  quickly 
regulating  its  intensity  so  that  it  could  be  lowered  or  raised 
like  gas.  Mr.  Lang  has  perfected  a  plan  whereby  this  can 
be  accomplished  and  we  can  now  dispense  with  gas — a 
decided  advance,  especially  on  a  hot  summer's  day  in  a 
stuffy  dark  room. 

The  study  of  otology  and  laryngology  is  not  so  satisfac- 
tory to  the  student  in  London  as  that  of  ophthalmology. 
The  London  Throat  Hospital  (Golden  Square,  clinics  every 
afternoon  and  evening)  with  Wolvenden,  Hovell  and  Bond, 
is  perhaps  the  best  known  and  where,  all  things  considered, 
one  gets  nearest  the  patients — whose  name  is  simply  legion. 
To  obtain  privileges  of  any  value  in  this  direction  it  is,  how- 
ever, necessary  to  take  out  a  ticket  of  attendance  (3  guineas 
for  six  months, 5  guineas  perpetual,  from  the  secretary)  and 
to  wait  for  a  vacancy  on  the  staff  of  clinical  assistants,  if 
there  be  none  at  the  time  of  registration. 

Dr.  Dundas  Grant,  Mr.  Lennox  Browne  and  others  hold 
daily  clinics,  (beginning  at  2  p.m.  and  lasting  until  evening, 


'! 


fees  1  guinea  a  month)  where  the  student  may  see  a  large 
number  of  ear,  throat  and  nose  cases.  At  irregular  inter- 
vals lectures  are  given  on  otologic  and  laryngologic  sub- 
jects. 1  fear  it  will  be  a  long  time  before  London  is  able  to 
holdout  inducements  to  students  of  otology,  and  the  kin- 
dred specialties,  equal  to  those  so  freely  offered  by  Vienna 
or,  though  in  a  less  degree,  even  by  lierlin. 

I  regret  that  I  was  unable  to  attend  the  clinic  of  Mr.  Jon- 
athan Hutchinson — a  name  claimed  eijually  by  all  depart- 
ments of  medicine  and  surgery.  I  am  told  that  every  Lon- 
don hospital,  whether  devoted  to  general  surgery,  ophthal- 
mology, diseases  of  the  lungs  or  what  not,  furnishes  its 
quota  of  obscure  cases  for  review  by  this  truly  remarkable 
man.  Such  fathers  of  our  art  should  live  forever,  and  one 
may  well  wish  for  a  continuance  of  a  life  already  so  replete 
with  useful  years. 

One  of  my  missions  in  England  was  to  investigate  the  sub- 
ject of  the  color  sense.  In  my  opinion  we  have  as  yet,  no  the- 
ory that  satisfactorily  accounts  for  all  t'  e  color  phenomena, 
physiologic  and  pathologic,  commonly  met  with,  and  I  hoped 
to  find  light  upon  this  obscure  matter  in  the  work  of  Mr.  Lovi- 
bond  of  Salisbury,  who  has  been  engaged  in  investigatinj,' 
color  values  and  "chromometry"  for  twenty  years  past.  I 
have  long  felt  the  absurdity  of  scientific  men  using  sucli 
terms  as  "canary  yellow,"  "magenta,"  "grass  green,"  "Prus- 
sian blue,"  etc.,  as  their  most  definite  expression  of  a  color 
sensation.  In  his  search  for  universal  color  standards,  Mr. 
Lovibond  was  confronted  with  the  difficulty  of  finding  a 
pure  white,  bi  t  at  last  settled  upon  a  compressed  surface  of 
finely  powdered  lime  sulphate  as  giving  the  nearest  approacli 
to  white.  When  colors  are  viewed  through  a  tube  or  box, 
from  which  all  light  is  excluded,  the  slightest  difference 
between  them  can  be  readily  observed  if  the  colored  objects 
be  uniformly  illuminated.  This,  the  principle  of  Chribrefs 
chromophotometer,  enables  the  observer  to  add,  in  Mr.  Lovi- 
bond's  instrument  uniformly  graduated  yellow,  red  and 
blue  tinted  test  glasses  to  the  white  side  of  the  apparatus 
until  it  exactly  resembles  the  colored  object  under  examina- 
tion. When  both  objects  appear  exactly  alike,  the  glasses 
added  to  the  white  side  are  the  color  measure  of  the  colnr 


or  shade  under  examination.  The  result  is  always  given  in, 
niid  every  color  can  be  resolved  into,  terms  of  red,  blue  and 
yellow— according  to  the  Lovibond  scale.  TIiuk  a  colored 
powder  is  found  to  be  composed  of  1.4  standard  units  of  red, 
0.9  standard  units  of  blue  and  of  yellow  3.7  units,  or  a  cer- 
tain tluid  (beer,  drinking  water,  oil)  is  found  to  be  0.8  red 
and  0.50  yellow. 

.Not  only  have  we  in  this  scheme  a  universal  standard  of 
color,  but  other  uses  to  which  the  "tintometer"  is  put  ought 
to  interest  every  medical  man.  It  has  been  found  that  the 
amount  and  kind  of  adulteration  in  most  foods  and  commer- 
cial products,  as  well  as  the  impurities  commonly  found  in 
drinking  water  and  other  fluids  can  be  determined  by  the 
deviation,  measured  by  the  tintometer,  from  the  normal 
tint  of  the  pure  article.  Instead  of  making  a  laborious  and 
complicated  clfmir  examination  of  the  suspectc^d  com  ■ 
pound,  its  color  value  is  determined  in  a  few  minutes.  Such 
a  cliromometric  examination  is  usually  found  to  answer  all 
tlie  purposes  of  a  quantitative  analysis'.  In  this  way  the 
tintometer  is  now  employed  in  England  and  to  some  extent 
abroad,  by  all  sorts  of  commercial  houses  and  it  is  also  used 
with  great  success  by  the  health  departments  of  cities  fur 
the  ready  detection  of  impurities  and  adulterations  in 
milk,  water,  beer  and  other  foods.  The  iili(jhtest  departure 
(mill  jinriti/  ii'hether  in  food  or  hi  nuji  other  })roduct,  is  at  once 
,s//y*/«  hi/ a  taeatiurahle  and  corresjxjiidin;/  rariatiun  in  color. 

As  scientific  men  the  subject  of  color-music  ought  to  inter- 
est you.  The  July  number  of  the  Nineteenth  Century  contains 
an  article  dealing  with  this  matter — an  attempt  to  convert 
musical  tones  into  corresponding  color  harmc'  s.  I 
remained  one  day  longer  in  London  that  I  might  a  iid  a 
concert  in  St.  James'  Hall  where  upon  a  large  canvas  beau- 
tiful displays  of  color  combinations  were  given  as  an  inter- 
pretation of  the  music  rendered  by  a  good  orchestra.  Just 
/'""'  this  was  accomplished  I  could  not  discover  but,  a  priori, 
it  does  not  seem  opposed  to  our  idea  of  the  conservation  of 
energy  that  sound  waves  and  the  cerebral  sensations  they 
produce  should  be  convertible  into  those  of  color. 


6 


Tauih,  July  11,  ison. 

Owinjj  to  my  acciuaititaiico  with  the  American  iiu'dical 
colony  ill  I'ariH,  I  was  able  with  their  courteous  help,  to 
gather  many  items  of  interest  which  would  otherwise  have 
taken  a  much  lon^'ertinie  to  collect.  Drs.  Kvansof  ('hicaKo, 
MerKeson  of  Merrill,  Wis.aiui  Jehin-I'rume  of  Montreal,  are 
at  work  hero  and  express  themselves  as  j<i*t*iitly  pleased  with 
the  opportunities  for  study  in  all  departments  of  medicine 
and  surgery.  The  fees,  unlike  N'ienna,  are  (juite  nomimil 
(often  excellent,  courses  are  free)  and  every  stranger  (in 
contrast  to  London  and  Merlin)  is  welcomed  without  the 
least  introductory  formality. 

A  stud'Mits'  number  of  the  I'rcsHr  nu'dlfdli'  is  issued  every 
December  and  is  (he  best  medical  guide  to  Paris  1  could  Hnd 
and,  although  intended  for  undergraduates,  is  a  help  to  the 
visitor. 

The  fiiHlitnf  I'antnir  (Kue  Dutot,  25,  open  to  visitors  at  11 
A.M.,  apply  to  the  concierge)  was,  as  you  know,  built  and 
endowed  by  subscriptions  from  all  parts  of  the  world  and  its 
most  useful  work,  it  seems  to  me,  is  done  in  the  fine  labora- 
tories and  research  rooms  of  the  main  building.  There  are 
half  a  do/en  of  the  former  under  the  care  of  salaried  chiefs 
of  departments  who  also  instruct  students,  and  over  twenty- 
four  of  the  latter  given  up  to  advanced  workers  who  are 
conducting  original  investigations.  The  general  laboratory 
courses  (50  francs  for  two  months,  most  of  the  material  free) 
are  said  to  be  the  best  in  Europe.  The  research  rooms  are 
let  for  the  insignificant  sum  of  50  francs  a  month  and  the 
Institute  furnishesall  the  ordinary  apjjaratus  and  materials 

The  animal  rooms  conta.n  over  one  thousand  birds- 
guinea  pigs,  rats,  rabbits,  etc.  In  this  appropriate  way 
does  F'rance  make  a  generous  return  to  those  foreign 
countries  that  subscribed  money  for  building  the  Institute. 
Pasteur  has  his  private  apartments  in  the  buildings,  but 
since  the  illness  of  the  chief  the  management  of  the  Institu- 
tion has  fallen  entirely  into  theworthy  and  competent  hands 
of  Dr.  Roux.  The  city  of  Paris  presented  them  both  with 
medals  and  a  sum  of  money  a  few  days  ago. 

Among  the  most  important  work  done  at  the  Institute  and 
the  Children's  Hospital  is  that  in  connection  with  diphtheria 


— hy  Miirtniirek.  Ilu  tinda  that  I  he  dirie»HH  is  nut  alwayri  the 
rcHuit  of  tht)  diphthurica  bacilliitt,  Ho-calUul,  aloriH,  but  that 
that  riii(!r((t»rKariiHm  is,  in  many  (tanes,  aHsociatcd  with  otherH, 
iinlal)ly  the  HtrnptocociMis,  and  the;  HyinplninH  may  be  mixed 
plifiiomciia  diiu  tu  a  compoHitu  inTuution.  In  certain 
instances  the  systiMnic  poiHonin^  may  be  chiefly  a  Htrepto- 
(Mx'.cdH  intoxication.  If  thiri  be  true,  we  have  an  explaruition 
(if  lh(t  irreguliir  action  of  Hehrin^^'H  heilHcrum  ;  antiloxin  is 
p  )\verle:is  in  a  caHe  of  diphtheria  largely  dut;  to  poiHotiin^ 
by  the  streptococcus.  Marmarek  consecjuently  pntposea  not 
only  to  rej^ulate  the  dose  of  antitoxin  by  the  proportioti  of 
diphtheria  bacilli  present  in  the  exudation,  but  to  K>ve  doses 
of  streptococcus  toxins  when  (hat  coccus  is  found.  He 
ex|iects  to  have  the  antidote  ready  for  general  use  in  a 
month  or  two. 

Marmarek  is  of  opinion  that  the  chief  danger  to  which  the 
tul)ercular  patient  is  exposed  is  a  secondary  infection  of  his 
lesions  by  streptococci. 

I  was  also  interested  in  the  investigations  of  Cenarelli  in 
typhoid  fever.  Most  animals  can  not,  under  ordinary  con- 
ditions be  inoculated  with  the  disease,  but  he  found  that 
this  immunity  practically  disap{)ear8  and  that  they  exhibit 
all  the  characteristic  lesions  of  enteric  fever  when  they  are 
ill-feu,  kept  in  lilthy,  badly  ventilated  quarters  or  exposed 
for  some  time  to  sewer  gas  before  receiving  the  typhoid 
poison.  The  inference  is  that  human  beings  are  much  more 
likely  to  resist  this  form  of  intoxication  if  they  live  hygieni- 
cally  and  in  a  healthy  neighborhood — a  doctrine  taught  by 
our  fathers  before  the  days  of  bacteriologic  laboratories. 
There  is  a  public  hydrophobia  clinic  connected,  as  an  out- 
door department,  with  the  Institute,  where  from  eighty  to 
ninety  patients  are  daily  treated;  the  average  treatment 
lasts  fifteen  days  and  the  method  is  just  the  same  as  that 
carried  out  in  Chicago  by  our  own  Dr.  Lagorio.  By  the  way, 
Chicago  is  the  only  Pasteur  station  except,  I  think,  Havana 
and  New  Orleans,  marked  on  the  large  map  of  North  Amer- 
ica at  the  Institute.  I  could  not  discover  why  New  York, 
with  Gibier's  station,  had  been  omitted. 

I  saw  the  original  Pasteur  filter,  invented  by  Chamber- 
land,  one  of  the  department  chiefs  at  the  Institute,  and  am 


8 


inclined  to  think  more  highly  of  it  than  I  did  of  those  put 
on  the  Chicago  market.  It  is  used  here  for  the  separation 
(underpressure)  of  their  toxins  from  the  various  microbes. 
As  you  are  aware,  the  filter  is  practically  a  porcelain  cup, 
dense  enough  to  separate — to  a  bacteriologic  demonstration 
— even  the  smallest  organism  from  contaminated  drinking 
water.  I  suspect,  however,  that  regular  boiling  and  cleans- 
ing of  the  porcelain  cylinder  and  its  attachments  would  be 
a  useful  proceeding  in  the  case  of  a  filter  daily  employed  in 
the  purification  of  Chicago  water. 


II. 

Paris,  July  14, 1895. 

Gentlemen: — Perhaps  the  most  noticeable  fact  connected 
with  the  more  prominent  oculists  of  Paris  is  their  foreign 
names  and  origin.  We  find  several  Germans,  a  Pole,  a  Greek, 
a  Netherlander  and  even  a  Canadian  graduate  on  such  a 
list.  Whatever  else  this  may  mean,  it  is  at  least  evidence  of 
the  tolerant  and  cosmopolitan  character  of  French  surgery. 
Evidently,  also,  they  have  been  asked  by  the  French  public, 
not  where  they  were  from,  but  what  they  knew  about 
ophthalmology. 

Probably  the  best  known  ophthalmologist  in  Paris  is  De 
Wecker  (public  clinic  55  Rue  Chercher  Midi,  4  p.m.  daily; 
operations  at  5  p.m.),  one  of  the  fathers  of  ophthalmology 
and  justly  celebrated  as  author,  teacher  and  operator.  He 
has  always  a  large  following  of  students  and  patients  and 
is  very  courteous  to  strangers.  He  showed  me  his  new  glass- 
and-nickel  steel  operating  chair,  made  on  the  model  of  one 
in  which  he  said  he  had  done  30,000  operations.  He  gave  his 
own  anesthetic  on  several  occasions,  not  for  want  of  an  as- 
sistant but  because  he  had  "views"  upon  the  subject  of 
general  anesthesia.  De  Wecker  prefers  the  illumination 
from  a  small  electric  hand-lamp,  while  operating,  to  sun- 
light, as  he  thinks  that  the  operator,  his  assistants  and  the 
onlookers  can  all  see  better.  It  seems  to  me  that  this  is 
merely  an  example  (and  we  find  many  of  them  among  sur- 
gical appliances)  of  the  adaptation  of  an  instrument  to  the 
requirements  of  a  particular  surgeon.  He  finds  that  some 
form  of  instrument  suits  him  better  than  any  other  and 


m 


.1 


9 


forthwith  discovers  reasons  why  it  should  be  adopted  by  the 
rest  of  the  world.  De  Wecker  is  markedly  short-sighted 
and  is  obliged  to  approach  his  own  eyes  to  the  patient's  face 
while  operating ;  consequently  an  electric  lamp  is  better  for 
all  concerned  when  he  is  operating. 

I  saw  Panas,  another  well-known  oculist  (professor  in  the 
University,  Flotel  Dieu,  fifty-nine  beds  for  eye  patients,  en- 
trance off  the  Place  Notre  Dame,  noon  daily,  operations  2 
I'.M.),  and  the  man  who  advocates  the  substitution  of  biniodid 
of  mercury  for  sublimate  as  an  antiseptic  in  surgery,  on  the 
ground  that  it  is  less  irritating  than,  is  quite  as  good  a 
germicide  as,  and  can  be  more  effectually  employed  in  one- 
half  the  dose  of  mercuric  chlorid.  Lately  he  has  been  in 
the  habit  of  using  the  iodid  dissolved  in  sterilized  olive  (or 
almond)  oil  as  an  antiseptic  application  to  the  lids  and 
lashes  (and  for  hypodermic  injection  in  general  medication) 
before  operating  for  cataract.  The  ocular  region  generally 
is  thoroughly  cleansed  the  evening  before  the  operation  and 
the  oil  applied.  The  eye  is  then  bandaged  until  the  moment 
of  operation.  Laboratory  experiments  have  proved  that  the 
conjunctival  sac  and  the  lid  edges  contain  fewer  pathogenic 
bacteria  after  this  treatment  than  when  any  other  plan  is 
followed;  also  the  evidences  of  ocular  hyperemia  are  few 
or  wanting.  During  the  operation  he  uses  a  large  Graefe 
knife  and  cuts  through  one-half  the  corneal  circumference. 
His  extractions  are  without  iridectomy  and  he  does  not 
hesitate  to  employ  what  appeared  to  me  to  be  a  good  deal 
of  force  and  much  manipulation  in  replacing  the  iris,  using 
a  large  scoop-like  repositor.  But  this  rough  treatment,  he 
says,  is  never  followed  by  iritis.  Pie  has  given  up  the  use  of 
the  syringe  for  washing  out  the  anterior  chamber  after 
removal  of  the  cataract,  since  employing  the  iodid  oil  solu- 
tion. The  presence  of  pathogenic  microbes  is  what  he  fears 
in  producing  ocular  inflammation  rather  than  traumatism 
(c.(j.,  the  use  of  the  iris  repositor)  or  foreign  bodies  in  the 
anterior  chamber — such  as  lens  matter  and  capsular  remains 
after  cataract  extraction.  He  uses  eserin  ointment  1  per 
cent,  after  the  operation  for  cataract,  then  iodoform  dressing, 
both  eyes  being  bandaged  for  three  days. 

Some  of  the  English  operators,  Lang,  for  example,  always 


examine  the  eye  twelve  hours  after  such  operations,  as  in 
their  experience  prolapse  of  the  iris  occurs,  if  at  all,  within 
that  time.  They  also  say  that  the  prolapse  is  more  easily 
dealt  with  then  than  later. 

After  enucleation,  Panas  sutures  the  conjunctiva  and  puts 
in  rubber  drainage,  thereby  securing  a  better  socket  for  the 
artificial  eye. 

I  saw  a  good  many  cases  dressed  with  iodoform  in  all  the 
clinics,  and  I  can  not  help  thinking  that  the  French  nose  is 
after  all  less  susceptible  to  that  odorous  application  than 
are  our  American  olfactories ;  you  will  remember  that  even 
the  poorest  public  patient  objects,  with  us,  to  iodoform  dress- 
ings when  applied  to  the  nasal  region. 

In  the  clinic  of  Abadie  (172  Boulevard  St.  Germain,  1  to 
4  daily,  operations  at  3)  I  saw  the  chief  give  a  subconjunc- 
tival injection  of  one  drop  of  a  weak  eserin  solution  imme- 
diately after  removal  of  cataract.  He  did  his  extraction 
without  iridectomy,  like  almost  all  the  French  operators — 
as  opposed  to  the  English  surgeons,  of  whom  it  may  be  said 
that  the  converse  is  true.  Abadie,  for  cataract  extraction, 
uses  an  eye  speculum  with  the  spring  turned  toward  the 
nose,  having  previously  cleansed  the  conjunctival  sac  with 
cotton-covered  retractors.  This  latter  proceeding  recom- 
mended itself  to  me  since  reading  Gasparini's  report,  in 
which  he  showed  that  the  useful  action  of  certain  fluids 
(borated  solutions,  sterilized  water,  weak  bichlorid  mixtures, 
etc.),  employed  in  irrigating  the  eye,  depends  not  so  much 
upon  their  germicidal  powers  as  upon  the  stream  of  water 
acting  as  a  mechanical  agent  in  detaching  and  washing  away 
the  colonies  of  cocci. 

Abadie's  first  assistant  kindly  showed  us  a  number  of 
syphilitic  patients  whom  he  was  treating  after  the  method 
of  Marcelli,  of  Milan,  by  the  intravenous  injection  of  mer- 
curic cyanid.  When  employed  in  the  usual  hypodermic 
manner  the  following  is  the  formula  commonly  prescribed: 

Cyanid  of  mercury 1      grm. 

Muriate  of  cocain 0.50  ctgr. 

Distilled  water 100      grms. 

Of  this,  1  cubic  centimeter  every  two  days.  The  cocain  is 
omitted  when  the  injection  is  vnsk^e intravenous, i.e.,  into  any 


11 


of  the  superficial  veins  of  the  arm,  and  a  centij?ram  is  given 
at  one  dose  every  two  days.  A  special  syringe  is  used,  there 
is  very  little  pain  and  I  saw  no  disagreeable  after-effects. 
Abadie  claims  from  this  treatment  much  better  and  earlier 
results  than  when  mercury  is  given  by  inunction  or  by  any 
other  method. 

The  Quinze-Vingts,  probably  so-called  because  it  had  300 
beds  when  first  founded,  is  one  of  the  oldest  hospitals  in 
I'aris  und  has  connected  with  it  the  largest  indoor  eye  hos- 
pital in  the  world — the  Clinique  Nationale  d'  Ophthahtiologie 
(Kue  de  Charenton,  28,  daily  clinics,  11  to  12,  operations  at 
1  P.M.)  with  190  beds  and  a  very  large  dispensary  practice. 
Prominent  on  its  staff  of  surgeons  is  A.  Trousseau,  a  mem- 
ber of  that  family  illustrious  in  the  annals  of  French  medi- 
cine. He  is  a  very  genial  man  and  received  us  with  great 
kindness.  I  have  never  seen  a  more  rapid  operator  in  any 
department  of  surgery.  The  way  in  which  cataracts  were 
removed,  squints  straightened  and  lid  operations  performed 
was  simply  amazing. 

The  Gilet  de  Grandmont  operation  for  congenital  ptosis  was 
done  in  two  minutes,  while  cataracts  were  extracted  in  about 
twenty  seconds !  For  the  latter,  which  were  without  iridec- 
tomy, he  used  only  a  Graefe  knife  like  the  English  operator 
Critchett.  Separating  the  lids  with  his  left  thumb  and  fore- 
finger, he  quickly  punctured  the  cornea,  used  the  point  of 
the  advancing  knife  as  a  cystotome,  made  his  counter-punc- 
ture, completed  the  incision,  pressed  upon  the  lower  third  of 
the  cornea  with  the  back  of  the  knife,  and  before  one  could 
say  "  Jack  Robinson,"  the  opaque  lens  lay  upon  the  cheek. 
I  saw  him  do  half  a  dozen  such  operations,  with  good  imme- 
diate results,  inside  of  fifteen  minutes.  A  starch  bondage 
was  applied  in  all  the  cases.  To  this  hospital  are  also  at- 
tached Valude  (operates  every  Thursday  at  2  p.m.),  Kalt, 
who  sutures  the  corneal  wound  after  cataract  extraction  to 
prevent  hernia  of  the  iris,  and  others.  Regular  instruction 
in  ophthalmology,  illustrated  by  cases  from  the  vast  supply 
of  clinical  material  at  hand,  is  given  by  members  of  the 
staff  and  is  practically  free  to  all  comers.  The  assistants  in 
this  hospital  have  unusual  opportunities  for  doing  major 
operations  upon  the  eye.    They  are  chosen  by  competitive 


tl 


li 


examination  and  the  appointments  are  eagerly  sought 
after. 

Landolt  (12  to  2,  at  his  clinic,  Rue  St.  Andre'  des  Arts,  17) 
is  the  ophthalmologist  who  has  translated  into  simplex  lan- 
guage those  complicated  formulae  connected  with  physio- 
logic optics  to  be  found  in  the  exhaustive  treatises  of  Helm- 
holtz  and  Bonders.  Indeed,  most  of  the  smaller  works  and 
text-book  chapters  on  the  refraction  of  the  eye,  that  have 
appeared  during  the  past  ten  years,  have  been  copied  from 
his  masterpiece,  "  On  the  Refraction  and  Accommodation  of 
the  Eye."  He  is  still  a  young  man  and  speaks  and  writes 
admirable  English.  Every  American  visitor  or  student  may 
count  upon  receiving  a  cordial  welcome  from  him.  I  regard 
his  early  and  smaller  work  on  the  "Examination  of  the  Eye" 
as  the  best  thing  of  the  kind  yet  published.  Unfortunately, 
it  has  been  out  of  print  for  several  years  and  so  far,  the 
author  has  not  seen  fit  to  re-write  it. 

The  Hospice  de  la  SalpHriere,  combination  of  hospital,  poor- 
house  and  lunatic  asylum  with  its  3,800  beds  for  women  has 
attached  to  it,  as  surgeon  oculist.  Dr.  Parinaud  (his  own  clinic 
•  in  the  Avenue  de  Clichy,  No.  50,  is  held  daily)  who  is  probably 
best  known  as  an  authority  on  hysterical  amblyopia  and  on 
the  relations  of  the  eye  to  nervous  diseases  generally.  I  saw 
several  of  his  cataract  cases  where  the  corneal  incision  was 
made,  v,ithout  subsequent  iridectomy,  within  the  clear  cor- 
nea in  such  a  manner  (he  claimed)  as  to  insure  early  heal- 
ing of  the  wound  and  to  form  a  sort  of  corneal  dam  against 
extrusion  of  the  iris.  His  clinic  is  a  very  interesting  and 
instructive  one  and  might,  with  benefit,  be  attended  by 
every  medical  visitor  to  Paris.  He  speaks  little  or  no  Eng- 
lish. Parinaud's  first  assistant,  Morac,  has  also  written  ex- 
tensively on  subjects  of  special  interest  to  the  neurologist. 

The  personality  of  Galezcwski,  one  of  the  oldest  and  best 
known  oculists  in  the  French  capital  (Rue  Dauphine,  41, 
daily  1  to  3,  operates  3  to  4)  rises  superior  to  one's  judgment 
of  him  as  an  ophthalmologist.  He  has  by  far  the  largest 
private  clinic  in  Paris  and  probably  as  large  a  student  fol- 
lowing as  any  other  teacher.  In  his  overcrowded  and  far 
from  (surgically)  clean  operating  room,  aseptic  conditions 
can  not  possibly  be  obtained  nor  was  there,  so  far  as  I  could 


13 


learn,  that  attention  given  to  the  measurement  of  refra^,- 
tive  errors  or  the  correction  of  muscular  anomalies  which 
one  sees  in  some  French  and  in  most  English  dispensaries. 
Still  there  is  a  peculiar  fascination  about  the  man  and  his 
teachings  that  seems  very  attractive  to  students  and  pa- 
tients. At  the  same  time  one  can  not  help  wondering 
whether  the  enthusiastic  hopes  of  these  patients  are  more 
frequently  realized  than  are  the  calmer  prognoses  extended 
to  the  clientele  of  other  dispensaries.  The  crowd  at  Galezow- 
ski's  seems  as  large  and  expectant  as  when  I  first  visited 
I'aris  in  1886.  I  do  not  intend  by  these  words  to  depreciate 
the  work  which  Galezowski  has  done  for  medicine  generally, 
because  that  is  valuable  and  forms  a  part  of  modern  ophthai- 
mology. 

This  ophthalmologic  sketch  would  be  incomplete  without 
a  reference  to  Dr.  George  J.  Bull  (4,  Rue  de  la  Paix,  2  to. 4 
i daily)  an  American  graduate,  who  has  won  a  place  in  the 
front  rank  of  Parisian  oculists.    He  was  associated  for  a 
[number  of  years  with  Javal  of  ophthalmometer  fame  and 
[that  instrument  probably  owes  more  to  Bull  than  he  is  will- 
ing to  admit.    At  any  rate  his  compatriots  in  medicine  will 
{ always  find  him  willing  to  advise  them  as  to  the  best  way  to 
[get about  the  Paris  hospitals. 

I  regret  that  I  was  unable  to  visit  Meyer,  Oswalt,  Darier  or 
Id'Espagnet  as  I  intended,  and  will,  consequently, say  nothing 
about  them,  but  the  man  who  is  interested  in  diseases  of  the 
[eye  ought,  when  time  permits,  look  them  all  up. 

Since  I  last  visited  this  city,  several  surgical  instrument 
[makers  and  dealers  in  optical  apparatus  have  come  to  the 
front.  In  addition  to  the  well  known  firms  of  Collin,  Nachet 
land  Liier  (now  at  No.  6,  Rue  Antoine-Dubois)  I  have  had  sat- 
isfactory dealings  with  Roulot,  58  Quai  des  orfeores  and  Ma- 
nor et  Genisson,Rue  Racine  23.  As  the  question  of  surgical 
lappliances  so  frequently  arises  in  the  case  of  the  medical 
jtraveler,  let  me  give  it  to  you  as  my  opinion  that  London 
[still  retains  her  old  preeminence  as  the  place  to  buy  most 
jcutting  instruments,  but  that  in  other  respects  New  York 
[excels.  With  the  exception  of  certain  souvenirs  de  voyage, 
jwhich  one  picks  up  in  every  city,  and  the  knives  and  scissors 
lof  London,  I  would  not  now  buy  a  franc,  a  gulden  or  a 


/ 


it 


14 


mark's  worth  of  office  furniture.  It  can  be  better  and  almost 
as  cheaply  purchased  in  our  own  country.  I  believe  that  we 
shall  be  able,  before  many  years,  to  say  the  same  thing 
about  our  medical  instruction.  At  least  such  is  the  impres- 
sion made  upon  me,  by  comparing  what  I  have,  so  far,  seen 
of  French,  German  and  English  methods.  In  my  next  letter 
I  hope  to  give  you  my  experiences  of  some  Dutch  and  Ger- 
man hospitals. 


III. 

Utrecht,  July  22,1895. 

No  better  situation  could  have  been  chosen  for  the  largest 
Dutch  ophthalmic  hospital  than  Utrecht.  The  city  is  about 
the  geographical  center  of  Holland  and  is  the  seat  of  a  uni- 
versity founded  in  1636  whose  medical  department  is  at- 
tended by  a  large  number  of  students.  Ophthalmology,  as 
well  as  other  branches  of  medicine,  owes  much  to  the 
Utrecht  school. 

It  was  the  celebrated  treatise  of  Donders  on  physiologic 
optics  (translated  into  English)  that  opened  the  way  for 
a  clear  understanding  of  the  refraction  of  the  ocular  media, 
the  mode  of  accommodation  and  the  action  of  the  extrinsic 
ocular  muscles.  All  these  and  many  other  important  mat- 
ters have  been  elucidated  by  his  worthy  successor.  Prof. 
H.  Snellen.  Two  years  ago  the  building  of  the  new  oph- 
thalmic hospital  (Nederlandsch  Gasthuis  voor  ooglijdtrs  49 
Bleijenburgstraat,  seventy  beds  with  over  five  thousand  out- 
door patients  and  five  hundred  operations  yearly — daily 
clinic  8  to  12,  operations  at  11)  was  opened.  This  is  s  very 
handsome  eye  hospital  with  wide  corridors,  high  yeilings 
and  cheerful  indoor  walks  for  the  patients.  It  ir,  built  so 
that  there  is  plenty  of  light  where  a  good  illumination  is 
required,  while  convalescents  can  go  about  in  covered  ways 
suited  to  their  condition.  In  this  building  Snellen  gives 
the  regular  university  courses  for  students.  Here,  too, 
other  teaching  is  donj  by  the  Professor's  sons,  Drs.  H.  J. 
and  W.  Snellen  and  the  other  assistants.  All  the  operators 
follow  the  Professor's  example  in  making  the  corneal  inci- 
sion (in  cataract  extraction)  extend  slightly  underneath 
the  conjunctiva.    Snellen  thinks  that  if  this  is  done  so  as 


15 


to  avoid  the  sclera,  that  no  bleeding  will  take  place  inta 
the  anterior  chamber  and  so  render  the  subsequent  steps 
of  the  operation  uncertain  and  difficult.  This  is,  as  you 
know,  the  chief  objection  to  the  conjunctival  flaps.  Its 
chief  advantage  is  that  such  a  wound  heals  in  a  few  hours 
and  binds  the  edges  of  the  cornea  closely  together.  When 
he  does  an  iridectomy,  as  part  of  cataract  removal,  he  favors 
the  preliminary  operation  and  performs  it  some  six  weeks  be- 
fore. When  there  is  increased  intra-ocular  tension, a  sluggish 
pupil,  posterior  synechia  or  an  unripe  lens  he  would  advise 
it.  At  the  time  of  the  operation  a  4  per  cent,  solution  of 
pilocarpin  is  instilled,  instead  of  eserin  which  is  often  very 
painful  and  irritating.  After  dressing  the  eye,  subsequent 
to  any  operation  where  the  eyeball  has  been  opened,  a  thin 
oval  aluminum  shield  (about  4x3  inches)  is  placed  over 
the  ocular  region  and  this  is  kept  in  place  by  adhesive 
straps.  The  patient  is  now  carried  to  bed  on  a  litter  made 
of  poles  and  side-pieces  run  through  folds  made  in  the 
under  operating  sheet.  He  is  allowed  to  sit  up  the  next 
day,  when  the  lids  are  also  opened  for  examination. 

I  was  courteously  allowed  to  examine  a  large  number 
of  cataract  cases  operated  upon  at  various  dates,  and  was 
greatly  pleased  with  their  appearance  and  the  absence  of 
complications.  The  Dutch  people  are  notoriously  clean 
and  live  in  well-ventilated  houses.  I  was  consequently  not 
surprised  to  learn  that  they  are  pretty  free  of  diseases  of 
the  lids  and  conjunctiva.  Dr.  Snellen  informed  me  that  in 
Utrecht,  with  a  population  of  100,000,  he  sees  barely  (i  or 
7  cases  of  trachoma  yearly.  On  the  other  hand,  among 
members  of  the  large  Jewish  colony  in  Amsterdam  (most  of 
whom  work  in  factories  and  live  in  dirty,  ill-ventilated  tene- 
ments) granular  lids  has  been  endemic  for  over  a  century, 
and  has  apparently  resisted  all  attempts  to  eradicate  it. 

Professor  Snellen  is  at  present  engaged  in  perfecting  the 
ophthalmometer  and  believes  that  the  University  optician 
(office  in  the  Physiologic  Institute)  has  succeeded  in  grind- 
ing the  prisms  and  other  lenses  connected  with  the  instru- 
ment with  a  precision  not  attained  by  Parisians  or  other 
workers.  He  also  showed  me  a  new  scheme  for  testing  the 
color  vision  of  railway  employes.    This  consists,  essentially 


lb 


of  illuminated  colored  discs  of  glass  which  are  exposed  for  a 
second  or  less,  to  the  view  of  the  person  under  examination, 
by  means  of  the  rubber  ball  and  shutter  used  in  the  ordinary 
photographic  camera.  The  size  of  the  disc  and  its  distance 
from  the  eye  correspond  to  the  visual  angle  for  which  the 
Snellen  test  types  are  arranged.  The  short  exposure  and 
artificially  illuminated  test  color  make  it  more  difficult  for 
the  color-blind  person  to  escape  detection  than  when  the 
Holgren  wools  are  alone  employed.  Moreover,  the  Snellen 
apparatus  can  be  used  at  night  time  and  the  illumination 
does  not  vary,  as  does  that  of  any  other  method  that  depends 
upon  daylight. 

It  seems  to  me  that  at  least  a  portion  of  the  post-graduate 
student's  stay  in  Europe  might  profitably  be  spent  in  one  or 
more  of  the  smaller  university  towns  like  Utrecht.  He  would 
in  this  way  escape  the  over-crowded  clinics  of  larger  citie? 
like  Vienna,  and  be  able  to  get  nearer  both  patients  and 
teachers.  It  is  true  that  in  the  case  of  Utrecht,  for  example, 
the  average  student  does  not  know  and  would  not  care  to  give 
time  to  the  study  of  Dutch,  but  since  both  Professor  Snellen 
and  his  assistants  speak  admirable  English,  and  many  of 
the  patients  understand  a  little  German,  this  drawback  is 
not  a  serious  one.  I  think,  also,  that  it  is  a  mistake  for  the 
student  of  German  medicine  to  give  all  his  time  to  Berlin 
and  Vienna,  where  he  often  has  to  take  his  chances  with  the 
members  of  a  large  class  in  getting  partial  views  of  opera- 
tions between  the  heads  and  over  the  shoulders  of  numerous 
assistants  who  crowd  about  the  operating  table.  In  smaller 
places,  like  Prague,  Konigsberg,  Gottingen,  Kiel,  Buda- 
Pesth,  etc.,  the  American  student  will  generally  have  the  ad- 
vantage of  personal  instruction  from  as  good  teachers  as  lie 
will  find  in  Vienna,  and  will  secure  advantages  and  oppor- 
tunities which  he  can  not  hope  for  even  in  the  much-vaunted 
and  more  costly  courses  of  the  Austrian  capital. 


IV. 


Berlin,  July  30, 1895. 
There  have  been  remarkably  few  changes  in  the  personnel 
of  the  Berlin  medical  faculty  during  the  past  eight  years. 
It  would  require  more  space  than  I  have  at  my  disposal 


17 


even  to  mention  all  the  celebrities  at  whose  feet  students, 
both  graduate  and  undergraduate,  might  sit  at  this  great 
teaching  center.  I  renewed  my  acquaintance  with  so  many 
of  them  as  T  could  find  in  town.  This  is,  however,  the  time 
of  the  midsummer  vacation  which  every  North  (German 
keeps  who  can. 

Vlrchow  is  still  working  away,  pretty  much  as  usual.  His 
celebrated  early  morning  (Patkologisches  Institut,  Chariti, 
Men.,  Wed.  and  Sat.,  8  to  10  a.m)  demonstrations  in  patho- 
logic anatomy  and  microscopy  is  just  ended  but  will  begin 
again,  like  all  the  other  university  classes,  with  the  winter 
semester  about  the  middle  of  October  and  last  until  March. 
Virchow's  former  assistant,  now  Professor  Israel — well 
known  friend  of  the  American — also  gives  courses  on  pa- 
thology in  the  same  place. 

Berlin,  when  the  convenience  of  the  post-graduate  student 
and  the  opportunities  for  study  are  concerned,  is,  to  my 
mind,  superior  to  London,  while  equivalent  courses  are  much 
less  expensive  than  those  of  Vienna.  In  the  latter  city  every 
thing  medical  practically  centers  about  the  le^rge  AUgemeine 
Krankenhaus ;  there  is  no  running  about  to  distant  hospitals 
or  lecture  rooms  for  instruction  or  to  witness  operations. 
Both  the  regular  University  lectures  and  the  other  Vienna 
courses  (which  go  on  month  after  month  with  little  change) 
on  the  same  or  allied  subjects,  are  generally  so  arranged 
that  one  can  constantly  pursue  even  a  single  line  of  study 
without  much  conflict  of  lecture  hours.  The  proportion  of 
teachers  who  speak  English  is  probably  greater  in  Vienna 
than  in  either  Paris  or  Berlin. 

/Although  Vienna  is  perhaps  the  best  place  for  the  student 
who  has  but  a  short  time  for  study  abroad,  yet  Berlin  and 
other  German  cities  occasionally  offer  superior  advantages 
in  most  departments  of  medicine  to  the  physician  or  surgeon 
who  can  remp.in  for  a  year  or  two.  A  prolonged  stay  will 
enable  him  to  learn  the  language  thoroughly  and  he  will  be 
better  able  to  mentally  digest  what  he  sees  and  hears.  He 
will  also  cultivate  the. acquaintance  of  teachers  (a numerous 
class  here)  who  follow  their  particular  studies  with  an  eye 
single  to  the  service  of  science — not  always  casting  furtive 
glances  at  the  pocket  books  of  the  clais  before  them.    The 


18 


University  issues  an  admirable  calendar  (to  be  had  at  every 
bool(  store)  and  time  table  of  lectures— a  pamphlet  that  will 
be  appreciated  by  those  who  have  studied  in  London  and 
Paris.  Armed  with  this,  and  having  chosen  a  centrally 
located  lodging  somewhere  near  the  Chariti,  he  can  profita- 
bly set  to  work  at  almost  any  time.  Berlin  should,  however, 
be  avoided  by  the  new  arrival  during  the  months  of  July, 
August  and  September  unless  he  has  previously  arranged  to 
act  as  locum  tenene  for  some  assistant  or  chief  of  clinic  wht> 
has  gone  for  the  usual  holiday.  Moreover,  unless  he  wishes 
to  follow  some  special  advanced  course  or  courses  it  would 
be  wise  for  him  to  begin  at  the  commencement  of  one  of  the 
semesters  (the  next  begins  October  26), or  one  of  the  Ferien 
curse — vacation  courses — for  practicing  physicians.  The 
latter  can  not  be  too  highly  praised  and  should  be  attended 
by  every  post-graduate  student  who  can  conveniently  reach 
Berlin  toward  the  end  of  September.  Full  information  re- 
garding each  course  with  the  address  of  the  clinic  where  it  is 
held,  name  of  teacher,  honorarium,  etc.,  is  given  in  an  an- 
nouncement to  be  found  in  most  medical  bookstores  or  at 
the  ■'  Langenbeck  house"  {10  Ziegelatrasse). 

The  lecturers  and  instructors  in  the  Ferien  courses  are  not 
confined  to  the  professors  and  privat  docenten  of  the  Univer- 
sity— although  these  are  in  the  majority — so  that  several 
competent  and  popular  instructors  outside  the  sacred  pre- 
cincts are  afiforded  an  opportunity  to  display  their  mbrits. 

As  many  of  these  courses  are  limited,  an  early  application 
is  usually  desirable  before  September  30,  when  certain  of 
them  begin.  They  all  come  to  an  end  on  October  26,  each  sin- 
gle course  lasting  four  weeks.  The  fees  are  usually  40  marks 
($10)but  range  from  20  marks— e.<7.,\Ve8tphal'8  class  in  mental 
diseases,  limited  to  five,  twice  a  week — to  150  marks  for  Ba- 
ginsky's  practical  course  in  otology,  limited  to  three,  and 
held  daily.  No  department  or  departmental  subsection  of 
medicine  or  surgery  seems  to  be  forgotten  in  this  scheme. 
For  Instance,  there  are  thirteen  courses,  no  two  of  which 
cover  the  same  ground,  in  bacteriology,  .lormal  and  patho- 
logic anatomy  ;  seventeen  in  internal  medicine  ;  eleven  on 
the  eye  and  ear ;  eight  on  gynecology  and  obstetrics ;  two 
on  physiology ;  six  on  medical  jurisprudence,  toxicology  and 


19 


liygiene ;  eight  on  nervous  diaeageg  and  electro-therapy  ;  Ave 
oil  general  surgery ;  fourteen  on  diseaBes  of  the  ear,  nose 
and  throat;  seven  on  syphilis,  sldn  diseases  and  diseases  of 
the  genito-urinary  organs,  and  one  on  medical  photography. 
Berlin  has  for  us  rather  a  melancholy  interest  in  pre- 
senting most  of  the  sanitary  advantages  that  our  large  towns 
lacl(,  and  but  few  hygienic  shortcomings.of  which  American 
cities  furnish  such  conspicuous  examples.  Every  medical 
visitor  should  inspect  as  part  of  his  studies,  the  extensive 
municipal  slaughter  houses  and  their  laboratories,  where 
rrenj  animal  is  examined,  macro-  and  microscopically  before 
its  ilesh  is  used  for  food.  And  woe  unto  the  butcher  who  dares 
expose  for  sale  a  carcass  laclcing  the  proper  sign  of  examina- 
tion !  He  should  also  inquire  into  the  system  by  which  a  daily 
and  thorough  (I  had  almost  said  non-political)  examination 
18  made  of  the  millc  sold  within  the  city  limits,  and  by 
wliich  acareful  search  is  instituted  for  adulterations  in  other 
forms  of  food.  These  matters  are  fully  gone  into  by  Meyer 
in  a  little  book  {Das  Gesetz  hetreffendden  Verkehr  mil  Nahrung- 
sinittrln)  published  by  Springer  in  Berlin.  During  this  study 
of  municipal  hygiene,  he  will  find  that  smallpox  is  practi- 
cally uni<nown  in  Berlin  and  that  everybody  is,  without  ex- 
ception, vaccinated.  Finally,  not  to  further  expand  this 
letter,  he  will  discover  that  the  sewage  of  the  town  does  not 
pollute  the  Sprey,  but  is  pumped  out  to, and  spread  upon  a 
municipal  farm  of  some  1,200  acres  where  it  is  used  as  a  fer- 
tilizer. This  estate  is  thus  made  to  pay,  over  and  above  cur- 
rent expenses,  more  than  3  per  cent,  on  the  original  outlay 
for  the  land. 


